Knowledge | Understanding | Rehabilitation

Isometric gluteus medius activation

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Often in hip dysplasia, we see over dominance of the tensor fascia lata (TFL) muscle which becomes hypertrophied over the anterograde-lateral hip. This muscle tends to try to stabilise the hip and pelvis instead of gluteus medius.


During a PAO the external obliques and rectus femoris are reflected off the pelvis and this can also result in TFL becoming more dominant post-operatively.


This can cause secondary issues such as gluteal tendinopathy, and TFL muscle spasm, as well as psoas irritation and increase anterior shearing of the joint.


Disclaimer: These are example exercises to aid activation of gluteus medius muscle, ensure that if you are a post-operative PAO patient you adhere to the weight bearing status that you are advised by your surgeon.


Reference: Sandell Jacobsen et al, 2018 'Muscle–tendon-related abnormalities detected by ultrasonography are common in symptomatic hip dysplasia,' Archives of Orthopaedic Trauma and Surgery, 138 (8) pp. 1059-1067.


Exercise:


  • Lying down with knees bent and shoulder width apart.
  • Belt around the top of the knees.
  • Place thumbs onto front/lateral side of hips and fingers onto back pocket area-behind hip bone.
  • Gently squeeze your knees out into the belt, like slowly turning the button up on a radio, you should feel the back pocket area gently activate, but not see any movement in TFL under your thumbs.

NB: This is a gentle activation exercise not a movement exercise.

Isometric gluteus medius activation with bridge.

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  • Lying on your back knees bent, 
  • Belt around knees, gently squeeze out as per first exercise, activating gluteus medius.
  • Slowly push through your heels raising your pelvis towards the ceiling, ensuring you keep the hip bones level, hold 5 secs.
  • Maintain the activation out into the belt throughout the exercise on the way up and down through the movement.

NB: You will feel a stretch over the front of the thigh-this is normal.

If you feel cramp in your hamstrings- your gluteus are not working enough to lift you up, so bring your heels closer to your bottom to engage the glutes and prevent the hamstrings from working.


Disclaimer: These are example exercises to aid activation of gluteus medius muscle, ensure that if you are a post-operative PAO patient you adhere to the weight bearing status that you are advised by your surgeon.

Isometric gluteus medius activation with step stance bridge

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Progression of last 2 exercises:


  • Lying on your back knees bent, place the foot of the leg you want to work more closer to your bottom and the other foot place slightly forwards so you are in a step stance.
  • Belt around knees, gently squeeze out as per first exercise, activating gluteus medius.
  • Slowly push through your heels raising your pelvis towards the ceiling, ensuring you keep the hip bones level, hold 5 secs.
  • Maintain the activation out into the belt throughout the exercise on the way up and down through the movement.

NB: You may feel more activation in the hamstring on the leg that is more forwards, this is normal.


Disclaimer: These are example exercises to aid activation of gluteus medius muscle, ensure that if you are a post-operative PAO patient you adhere to the weight bearing status that you are advised by your surgeon.

Sliders

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Sliders are a really good way to teach the static side to work gluteus medius in an isometric position and control the pelvis. Which is part of the role it plays in stabilising the pelvis during gait. 


Exercise: 


The static leg is the one working hardest despite not being the sliding leg.


  • Standing in a mini squat position//This ensures TFL cannot work.
  • Leaning elbows onto a surface.
  • Using your sock/ a plastic bag or a slider under your foot of the leg you want to work.
  • Gently slide the foot out to the side and slightly backwards-ensure your pelvis does not shift or move and the knee does not rise up or down. 
  • If you are doing the exercise correctly, you will feel an achey/burning sensation in your back pocket area of the static leg.
  • Try to build up the time you can manage this e.g. 30secs-1min.

NB: It doesn't matter how far the sliding leg goes-the important bit is that the pelvis stays totally still.


Disclaimer: These are example exercises to aid activation of gluteus medius muscle, ensure that if you are a post-operative PAO patient you adhere to the weight bearing status that you are advised by your surgeon.

Proprioceptive work on unstable surfaces

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The Berlin bed rest study in 2003 highlighted that with prolonged bed rest the deep stabilising muscles such as gluteus medius and minimus atrophy but the more superficial muscles are less effected. 


Therefore after prolonged bed rest the body will be more likely to recruit the superficial muscles in order to perform functional tasks. 


Completing rehabilitation on unstable surfaces such as the Bosu ball or wobble cushion, helps to increase recruitment of the deep stabilisers.


Exercises:


  • Wobble cushion- double leg balance, squats, balance eyes closed, only progress to single leg balance if no pelvis drop or trunk sway.
  • Bosu ball- Double leg balance, dead lifts, squats with feet slightly turned out, squats with weighted ball/bar, sumo dead lift (feet slightly turned out) minimal weight, upper limb weights maintaining double leg balance.

Disclaimer: These are example exercises to aid activation of gluteus medius muscle, ensure that if you are a post-operative PAO patient you adhere to the weight bearing status that you are advised by your surgeon.

Non-impact exercise for conservative management

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The hip joint takes approximately 8x body weight forces through it with impact based exercise.


If you are trying to conservatively manage your hip dysplasia, then I would advocate a reduction in impact based exercise and a significant focus on non-impact control work.


  • Swimming// Good cardiovascular work and full body workout.
  • Pilates- both mathwork and reformer pilates, helps to be able to control the limbo-pelvic segment and improve core stability, which is key in hip dysplasia.
  • Cycling// Spinning- I advise patients to either be up or down in the saddle and advise the instructor you will not be jumping up and down to certain beats, as this can cause overactivity of TFL and anterior shearing on the hip joint. So everything you do should be with control.
  • Ballet barre- I have found hugely beneficial for working gluteus medius to control the pelvis statically. Again adapt it so if you feel TFL overworking on the standing leg flex the trunk and the knee a little so it cannot fix.
  • Free body weights- all upper limb body weights completed standing on a Bosu ball- engages the deep stability system and the core.

Disclaimer: These are example exercises to aid activation of gluteus medius muscle, ensure that if you are a post-operative PAO patient you adhere to the weight bearing status that you are advised by your surgeon.